Canadian Maternity, Newborn, and Women’s Health Nursing Chapter 13: High-Risk Pregnancy

Pregnancy Risk Assessment Psychosocial Economic Nutrition-related Family-related considerations

Health Complications in Pregnancy Asthma Labour: assess vital signs; shortness of breath, increased respiratory rate, inspiratory and expiratory effort, oxygen saturation Asthma medicine; avoid Demerol or morphine Aim for adequate respiratory function; ability to cope with labour and birth; verbalize understanding of and fetal well-being; consistency of care

Health Complications in Pregnancy (cont.) Cystic fibrosis Observe for signs of malabsorption; monitor maternal weight and pancreatic enzymes, fluid and electrolyte balance; assess results of laboratory testing; adequate oxygenation Oral supplements, pulse oximetry, oxygen if required; breastfeeding permitted once sodium content has been determined

Health Complications in Pregnancy (cont.) Cardiovascular disease Types Class I: angina during strenuous or prolonged activity Class II: angina during vigorous activity Class III: symptoms with daily activities Class IV: symptomatic when resting

Health Complications in Pregnancy (cont.) Cardiovascular disease (cont.) Mitral stenosis Mitral valve prolapse Peripartum cardiomyopathy Atrial septal defects

Health Complications in Pregnancy (cont.) Cardiovascular disease (cont.) Collaborative management: pregnancy Physical examination, chest x-ray, ECG, blood gas analysis, echocardiogram Activity restriction, rest, iron supplementation; monitoring of mother and fetus Aim for adequate ventilation, tissue perfusion, hydration

Health Complications in Pregnancy (cont.) Cardiovascular disease (cont.) Collaborative management: labour and birth Vital signs; fatigue, difficulty breathing or shortness of breath, palpitations, swollen feet Reduce cardiac workload; goal is vaginal birth after 36 weeks’ gestation; hemodynamic monitoring, urine output, fetal monitoring

Health Complications in Pregnancy (cont.) Anemia Iron-deficiency anemia Assess hemoglobin, hematocrit, serum ferritin, free erythrocyte protoporphyrin Dietary review; prenatal vitamins, adequate iron; financial discussion regarding affordable diet

Health Complications in Pregnancy (cont.) Anemia (cont.) Sickle cell anemia Health history, blood count, reticulocyte count, blood urea nitrogen, glucose, direct bilirubin, urinalysis Folic acid supplementation Sickle cell crisis: acute episode of vascular occlusion

Health Complications in Pregnancy (cont.) Autoimmune diseases Systemic lupus erythematosus Frequent prenatal visits; monitor renal function, blood pressure, fetal health Corticosteroid therapy Labour: blood pressure, edema, proteinuria, urine output, cardiac monitoring, lung sounds, blood counts, fetal monitoring May need cesarean delivery This slide is overwhelming. Too much information. Need to use bullets and have a skeleton for reference not every word on the slide.

Health Complications in Pregnancy (cont.) Autoimmune diseases (cont.) Antiphospholipid syndrome Recurrent spontaneous abortions, unexplained pregnancy loss in second or third trimester, venous thrombosis, arterial thrombosis, stroke, SLE, autoimmune thrombocytopenia, prolonged clotting assay Treatment: prednisone with low-dose aspirin; low-molecular-weight heparin

Health Complications in Pregnancy (cont.) Infections HIV: test during pregnancy for early diagnosis and treatment of newborn Teach risks and benefits of care; determine level of knowledge about disease; plan for the newborn Assess emotional state and ability to cope Goal is to reduce maternal viral load before delivery; might have cesarean birth

Health Complications in Pregnancy (cont.) Infections (cont.) HIV (cont.) Therapy: start antiretroviral drug during pregnancy; give intravenously during labour and birth Test for HIV in newborn; ongoing medical treatment will be an extension of the care started during pregnancy

Health Complications in Pregnancy (cont.) Infections (cont.) Sexually transmitted infections (STIs) Prenatal care: inquire about sexual activity, previous STIs, risk factors Physical examination Screening, treatment, and follow-up throughout pregnancy Group B test done at 36 weeks gestation. Again this slide is too much information. Need to breakdone into bullets. So it is easy to read.

Health Complications in Pregnancy (cont.) Infections (cont.) Group B streptococcus Prenatal: swab at 35 to 37 weeks; if positive, need antibiotics at least 4 hours before birth Rubella Screen for rubella immunity at first prenatal visit; if no immunity, counsel to avoid contact with children who have not been immunized Group B test done at 36 weeks gestation. Again this slide is too much information. Need to breakdone into bullets. So it is easy to read.

Question A client develops a rash on her face, and rubella is suspected. Which transmission-based precautions would the nurse use when caring for this client? Contact precautions Droplet precautions Airborne precautions

Answer b) Droplet precautions Transmission of rubella is by droplet. Symptoms of rubella infection include a rash that may or may not be itchy that begins on the face and progresses to the trunk.

Health Complications in Pregnancy (cont.) Infections (cont.) Toxoplasmosis: thorough cooking of meat; avoid cat feces; use gloves when gardening; treat with spiramycin Cytomegalovirus: avoid contact with children in daycare or health care settings; encourage frequent hand washing Parvovirus: transmission by inhaled particles, hand-to-mouth contact, contaminated blood

Health Complications in Pregnancy (cont.) Renal and urinary problems UTIs and pyelonephritis Recognize difference between UTI and normal pregnancy changes Pyelonephritis: costovertebral angle tenderness, high fever, chills, myalgia, nausea, vomiting Antibiotics and antimicrobial agents Hygiene: wipe from front to back after urination and intercourse; extra fluid intake; cotton underwear

Health Complications in Pregnancy (cont.) Renal and urinary problems (cont.) Acute renal failure Sudden decrease in renal function Thorough health history and physical examination; vital signs; blood count, electrolytes, coagulation profile Fetal monitoring

Health Complications in Pregnancy (cont.) Diabetes mellitus May be pre-existing or gestational Potential nursing diagnosis Anxiety Deficient knowledge Risk for ineffective health maintenance Imbalanced nutrition Ineffective coping

Health Complications in Pregnancy (cont.) Diabetes mellitus (cont.) Review or teach blood glucose self-monitoring Promote diet management Encourage activity and exercise Administer insulin Monitor the fetus Provide care during labour and birth

Psychosocial Disorders and Problems Depression Changes in mood, sleep patterns, appetite, weight; feelings of helplessness Counselling, medications Bipolar disorder Cyclic patterns of depression and mania Medications may be teratogenic

Psychosocial Disorders and Problems (cont.) Intimate-partner violence May begin or increase during pregnancy Screen for suggestive indicators Nonthreatening, nonjudgemental approach SOS: Screen, Offer options, Safety

Psychosocial Disorders and Problems (cont.) Intimate-partner violence (cont.) Potential nursing diagnoses: Fear Anxiety Chronic pain Deficient knowledge Pain Impaired parenting

Psychosocial Disorders and Problems (cont.) Intimate-partner violence (cont.) Emergency safety plan; treat with respect and dignity; one-to-one nursing care Provide encouragement and support; information about community resources and shelters; ensure safety and well-being of mother and fetus

Psychosocial Disorders and Problems (cont.) Substance use Tobacco, alcohol, marijuana, cocaine, alcohol, opioids Methadone treatment in perinatal period Eating disorders Anorexia, bulimia

Obesity and Pregnancy Obesity Increased risk of hypertension, vascular disease, diabetes, cesarean birth Increased risk for fetal anomalies

Gestational Complications Hyperemesis gravidarum Severe nausea and vomiting Many theories regarding etiology Assess history, weight; complete blood count, electrolytes, liver enzymes, thyroid and bilirubin levels, urine for ketones and protein Monitor intake and output; nutritional counselling

Gestational Complications (cont.) Hypertensive problems Diastolic higher than 90 mm Hg Pre-existing hypertension Gestational hypertension With comorbid conditions (diabetes, renal disease) With preeclampsia (after 20 weeks, with proteinuria)

Collaborative Care: The Pregnant Client With Hypertension Monitor blood pressure, urine output, protein in urine, neurologic signs, renal function, edema, headaches, blood counts, liver function tests Fetal assessment: movement counts, nonstress tests, biophysical profile, Doppler studies Potential nursing diagnoses: anxiety, ineffective health maintenance, pain, risk for compromised family coping, social isolation Risk for seizures Pharmacologic treatments

HELLP Syndrome Hemolysis, elevated liver enzymes, low platelet count Epigastric pain, nausea and vomiting Hemolytic anemia, hepatic dysfunction Critically ill

HELLP Syndrome (cont.) Management depends on gestational age, maternal health, fetal status Ongoing monitoring of reflexes, intake and output, BP, fetal heart rate Antihypertensive therapy Magnesium sulfate to prevent seizures

Question A pregnant client is showing severe signs of gestational hypertension. What would the nurse expect when testing the client’s reflexes? Hyperreflexia Normal reflexes Absence of reflexes

Answer a) Hyperreflexia Neurological signs are very important to monitor when caring for a client with gestational hypertension. A client may present with brisk reflexes or hyperreflexia.

Preterm Premature Rupture of Membranes Premature rupture of membranes (PROM) Preterm premature rupture of membranes (pPROM): before 37 weeks Risk factors: nutritional deficiencies, substance use, multifetal pregnancy, infections, trauma Risk for chorioamnionitis, preterm birth, intrauterine death, amniotic band syndrome

Collaborative Care: Preterm Premature Rupture of Membranes Potential nursing diagnoses: constipation, anxiety, fatigue; risk for infection, maternal/fetal injury, deficient fluid volume; Maternal vital signs, fetal heart rate, abdominal palpation, inspection of perineal area, Nitrazine and fern tests Bed rest; assess for fever, chills, change in amniotic fluid; uterine contractions and fetal heart rate; assess amniotic fluid for lecithin/sphingomyelin ratio

Cervical Insufficiency/Incompetence Cervical insufficiency (painless cervical dilation) can progress to pPROM and preterm birth Risk factors: history of excessive cervical dilation for curettage or biopsy; previous cervical lacerations during childbirth; cervical or uterine anomalies Cerclage: suturing early in second trimester helps prevent cervical relaxation and dilation

Disseminated Intravascular Coagulopathy Complex coagulation disorder Complete blood count, prothrombin time, activated partial prothrombin time, fibrinogen, fibrin degradation products, d-dimer Monitor vital signs, oxygen saturation, blood pressure, pulse; replace blood volume; blood products, coagulation components; cardiovascular and respiratory support

Placental Alterations Placenta previa Placenta implants in lower uterine segment Risk factors: previous cesarean, previous placenta previa, uterine anomalies Complications: coagulopathy, postpartum hemorrhage Anticipate cesarean birth; blood administration

Placental Alterations (cont.) Invasive placenta Placenta implants into myometrium; doesn’t separate after birth Complications: hemorrhage Anticipate cesarean birth; blood administration Circumvallate placenta

Question A pregnant client has an ultrasound indicating the placenta extends up to the internal os but is not covering it. As the client’s nurse, you would classify this as which type of placenta previa? Type I Type II Type III Type IV

Answer b) Type II As her nurse, you should classify the condition as Type II placenta previa. Type II placenta previa is marginal implantation and includes the lower edge of the placenta extending to but not covering the internal os.

Placental Alterations (cont.) Placental abruption: placenta separates from uterus; bleeding may be visible or concealed Risk factors: hypertension; cocaine, alcohol, tobacco use; abdominal trauma Vaginal bleeding, pain in abdomen or back, uterine tenderness and rigidity Goal is stabilization; delivery method depends on risk for hemorrhage and risk for fetus

Collaborative Care: The Pregnant Adolescent Assess teen’s social support system Potential nursing diagnoses: fatigue, deficient knowledge, situational low self-esteem; risk for ineffective health maintenance, imbalanced nutrition, delayed growth and development

Collaborative Care: The Pregnant Adolescent (cont.) Provide information about options Educate about procedures, processes, risks, benefits; refer to community nursing, social services for psychosocial support Collaborate with health care providers to determine care plan

Multiple Pregnancy Increased potential for abnormalities, prematurity Assess by ultrasound: gestation, fetal growth, amniotic fluid volume Nutritional considerations; activity may need to be restricted

Multiple Pregnancy (cont.) Potential nursing diagnoses: anxiety, fear, constipation, imbalanced nutrition, ineffective health maintenance, deficient knowledge, compromised family coping Teach symptoms of preterm labour; prepare for emotional, financial, practical stresses Movement counts, Doppler studies, biophysical profiles, NST

Perinatal Loss Early pregnancy loss Ectopic pregnancy: implantation outside the uterus Gestational trophoblastic disease: proliferation and degeneration of trophoblastic villi Late pregnancy loss Stillbirth: fetal death at >20 weeks, >500 g

Collaborative Care: Pregnancy Loss Potential nursing diagnoses: chronic sorrow, social isolation, interrupted family processes; risk for dysfunctional grieving Provide privacy, pain relief, supportive care; acknowledge pain and grief After delivery: see and hold baby, save mementos Support groups